Emergency Room

Survey
Survey Planning,
Administration and Cost
SIDUC: AN INTEGRATED SYSTEM OF
DRUG USE SURVEYS
Key Informants
 SIDUC STANDARDIZATION
Information Reference Analized Data Periodicity
Source Population Population Collection

Treatment Patients Patients Interview Continue

Centers
Sample of
Emergency Patients hospitals and Interview Annual
Rooms 12 to 64 years Patients
Sample of Self
Student Students Schools & admnistered 2 years
Surveys Grades 8, 10, classes Questionnaire
12
Population in Sample of
Household households areas, Interview / 3 years
Surveys 12 to 64 years Households & Self admin
persons
 EMERGENCY ROOMS

Population of reference:
Patients of Emergency Rooms.
Analyzed population:
a) all patients b) typical weeks.
Judgmental sample.
Method of data collection:
Interview & laboratory analysis.
 FORENSIC MEDICINE
Population of reference:
Death by accident, homicide,
suicide.
Analyzed Population:
a) all , b) Typical weeks.
Method of data collection:
Autopsy and laboratory analysis.
 Steps to be Taken
A funding source or multiple sources
must be found (or no survey)
Decisions must then be made about
who will direct the research undertaking
What types of expert and staff support
will be needed, and
What is a realistic timetable
for the overall endeavor
for the major components
 Session Outline
Core Survey Activities
Personnel
Budget
Schedule
 Core Activities
1. Establishment of Advisory Committee
2. Develop Proposal
3. Seek Permission to conduct
4. Finalize Methodology
5. Training
6. Survey Implementation
Data Collection, Handling, Analysis,
Report Writing
 Advisory Committee
Stakeholders identification/representation
Ministry of Health
Public Hospital Authority
ER Director
Police
Ministry of Transport
Rep from private hospital
COB Research Unit

N.B> Can avoid problems at the end

Can help to sell the survey
Communications Regarding
Survey
Ministerial Responsibility (CMO)
Institutional Responsibility
Public Hospital Authority (PMH, RMH)
Institutional Review Boards/Ethics
Comm.
How to contact the chosen hospitals
Administrator
ER Manager
 Contact With Selected
Institutions
Step 1
An introductory letter to the Administrator,
informing him/her of the study and its
purposes. It will also:
Ask to inform the ER Manager of decision
Step 2
Contact the ER manager via telephone to
confirm that everything is in order just
prior. At this point:
 Project Personnel
Lead Investigator(s)
Core Staff
Site managers
Data Managers
Data Collection Staff
Doctors
Nurses
Medical Records Clerks
Consultant(s)
 Personnel Selection Process
Options
1. Advisory Committee to provide oversight of the
enterprise and the selection of the lead
investigators
AD: can help to engage people or organizations needed to
fund, conduct, or make use of the research
DIS: too many cooks in the kitchen and may introduce
political considerations into the process
REC: committee should deal with the broad policy and
financial issues and leave the scientific decisions to the
scientists
2. Recruitment of one or more individuals to run the
project
3. Individual researchers may take the initiative to
conduct such a survey
 Lead Investigator
Ideally will be a part of the activity
from beginning to end
Will provide the planning and
integration needed to be sure that the
end product matches the needs and
objectives
Should be trained social scientists with
some experience in survey research
techniques
 Core Staff
(Site Managers)
These key individuals will remain with the
study for its duration
Participate in various activities and make sure
that they are carried out according to plan.
Most likely will supervise various components
of the study, under the general direction of
the lead investigator(s)
Should be well educated and preferably have
some experience with research activities.
 Data Collection Staff
Decide whether the data will be collected
by individuals from outside the hospitals or
not
ER Staff: If the patients will trust the MDs or
Nurse to protect their confidentiality
Outside Staff: If the staffing situation presents
a challenge, then staff members must be hired,
trained, supervised and usually compensated
trained health social workers, trained field
interviewers from a survey research organization,
university students, etc
 Consultants
Overall Planning
To direct technical assistance at various stages, depending of course on the
areas of expertise of the lead investigators
If the lead investigators are new to this area of research, consider a short-
term consultation with an experienced expert in the initial planning stage,
again at the analysis planning stage, and perhaps at the interpretation stage
If brought in from abroad, seek the assistance and support of one of the
international organizations that deal with the control of drug abuse (UNODC,
OAS)

Sample Planning
Consultation with a sampling statistician also is likely to be very helpful,
again at an early point in the planning effort

Statistical Analysis
If neither a general consultant from the substance abuse field nor statistician
is able to help on data analyses, seek an expert on statistical analyses.
The job is usually not to actually conduct the analyses but to advise on the
choice of analyses and appropriate computer programs for conducting them.
Budget Planning
1. Personnel Costs
2. Non-Personnel Costs
 Factors that May Impact
Personnel Budget
Labor costs in the country
Whether it is necessary to use data collection
staff from outside the hospitals
The method of data entry
The need for technical assistance
The size of the sample needed and the size of the
country across which that sample will be spread
influence both staff and travel costs
Amount of the personnel assigned to plan and
conduct the ER survey who are already on the
payroll of a participating agency.
 Sample Budget Outline
PERSONNEL COSTS NON-SALARY COSTS

Lead investigators Office

Rental (if applicable)
R
F
Furniture (if applicable)
Field staff (if applicable) for __ weeks Equipment (as needed)
E
Supervisors/Site Manager Phones
Phones,, Fax,
Fax, Copy machine,
machine, Computers
Facilitators/MDs, Nurse, Med Rec. Supplies
S
Telephone
Telephone service
Core support staff Advertising/Recruiting Costs
Secretarial/Clerical Printing
Questionnaires
Questionnaires
Manuals
Manuals
Subcontractor Costs Brochures,
Brochures, instruction sheets, etc.
Final report
Final
For data entry (if applicable)
Shipping and postage
For any other services being purchased Questionnaires to hospitals
Questionnaires
Questionnaires
Questionnaires back from hospitals
Consultants Other
Other
Fringe benefits Travel Costs
For investigators
For
For
For field staff (if applicable)

Overhead charges (if any)

Estimated Budget for Bahamas Emergency
Room Drug Survey

Phase Specific Tasks Time Cost

Frame ($US)

Planning

Data Collection Training

Payment to
Facilitators
Other (Travel etc)

Data Handling Coding and

Editing
Data Entry
Post Cleaning
Data Analysis
 Estimated Budget for Bahamas Emergency
Room Drug Survey (Contd)
Report Writing Tabulation and
Graphics
Draft Report
Editing of Report

Printing and
Reproduction

Administrative Coordinator Fees

Costs
Supervisors Fees
?
Supplies
Questionnaire and
other Printing
General
administrative
costs
Total Estimated Cost
Survey Scheduling
 Scheduling Tips
Considerable time and expense can be saved by
undertaking several streams of activity
simultaneously
Anticipating which efforts need to be completed
before the next steps can proceed
Schedule should not be too abbreviated as there
may be some unexpected developments
Effort should be made to make realistic estimates of
the time necessary to complete each line of activity
Field staff should not be promised work until the
investigators actually expect to proceed with the
data collection (increased costs)
 Survey Scheduling
Hospital Recruitment
Data Collection
Analysis and reporting
Dissemination and utilization
activities
 Scheduling: Hospital
Recruitment
If participation is decided by central edict
(Ministry of Health), the process may be fairly
rapid.
If involved in the planning, this assures their willingness
to cooperate
If the individual hospitals or hospital authorities
have the authority to decline cooperation, the
process of securing cooperation can be a
substantial and time-consuming one.
Investigator(s) may have to write to each hospital
administrator inviting participation
Conduct a follow-up call (or possibly a series of calls) to
urge the hospitals participation and answer questions
Communicate with higher authorities, if their approval is
also required.
Scheduling: Data Collection
Once the main data collection is proceeding, the
responsible investigators should be monitoring
carefully the quality of the data being collected, to
be sure that those collecting it in the field are
following instructions, and to identify problems
early that might be rectified.

Plans can also be underway for how the data is to

be collected and forwarded and how the returned
data are to be coded and/or edited

Also, the investigators can begin planning the

analyses that they would like to conduct at the
completion of data collection and data cleaning.
 Scheduling: Analysis and
Reporting
Often not accorded the attention that they
deserve because not enough time and resources
were set aside for them at the outset of the study.

Be sure to leave a significant interval for the

analysis, interpretation, and writing of results.

At this late stage, normally only the lead

investigator(s) and an analyst or two are still
needed on the study staff, perhaps in addition to
a secretary.
 Scheduling: Dissemination
and Utilization Activities

Once the report is completed, arrangements

should be made to get it into the hands of
people likely to be influenced by its results.

The lead investigators may wish to meet

with certain groups, or make presentations
to particular audiences to whom the work
has relevance.
Policy and programmatic level
 Flow Chart of Activities for the
Conduct of a School Survey

INSTRUMENT PERSONNEL SAMPLE &

HOSPITAL
DEVELOPMENT AND Select lead
investigators RECRUITMENT
REFINEMENT
Design sampling plan
Hire core staff
Develop questionnaire
Secure data for

FIELD selecting hospital
Pretest questionnaire
PREPARATIONS sample

Develop field
Pilot test questionnaire
procedures Draw sample of
&
hospitals
field procedures
Hire and train field

staff Recruit the sampled
Make final revisions to hospitals
(if applicable)
questionnaire & field

procedures
Schedule the data
Flow Chart of Activities for the
Conduct of a E.R. Survey
CONDUCTING
THE MAIN SURVEY
Conduct full data collection

Code/clean/edit questionnaires

Enter data

Build computer file

Conduct data analyses

Write reports

Disseminate/utilize results
 Ethical Considerations
Data must remain completely confidential or
completely anonymous
no identifying information on a patients questionnaire
If specific identifying information for the individual
is contained on the questionnaires de-identify at
the earliest possible stage
Store the personally identifying information separately
from the answers to the rest of the questionnaire with
some type of link system
Avoid publicly identifying individual hospitals if
possible
Permission to participate at all levels
Commitment to use results
Emergency Room
Survey
QUESTIONNAIRE
DEVELOPMENT
 Factors That Impact Final
Content
1. Amount of time the medical staff can afford to
make available in an A&E setting
Quality, completeness
Treatment Vs Prevention
2. SIDUC Rules
3. Possibility of including other topics due to cost
sharing with other agencies
4. Ability of respondents to complete the
questionnaire
Complexity should not exceed respondents capabilities
 Levels of Priority

Highly Necessary to achieve

objectives. Questions likely
Recommended to be important to almost
any epidemiology study of
substance use

Recommended Those that should be given

very serious consideration
Risk and Protective Factors
Other sources Injury
Surv.
Questions from
Stakeholders

Optional May not measure concepts

of vital interest in every
 Sequence and Priority of
Elements In The
Questionnaire
Introduction
Background and demographic
characteristics
Age, Gender, Employment, Occupation
Use of alcohol
Use of illicit substances
Use of controlled substances
 List of Drugs
Alcohol Cocaine HCl. Coca Paste

Marijuana Tranquilizers Methamphetamin

es
Solvents and Sedatives Flunitrazepam
Inhalants (Rohypnol, etc)
Hallucinogens Amphetamines Crack Cocaine

Heroine Anticholinergic Ecstasy

s
Opium/Morphin Anti- Other
e depressants
 Defining Drugs For The
Respondent
Names and descriptions must be reviewed to see if they are
appropriate in the cultural setting in which they will be asked .
The main point is that the names used accurately
communicate to respondents which substance(s) should be
included in what they report, and which substances should
not, and under what circumstances.
To determine a list of appropriate slang or street names for
various drugs, the investigators may want to speak with
treatment professionals and known drug users in the age
group under study.
If a longer question stem is required to get the definition
clarified for your respondents, then that may be justified. (See
SIDUC Manual)
For legally prescribed drugs, it is important that the
respondents understand what occasions of use they should
and should not report in answering the questions.
 Definition of Drugs
Formal Name Street Name

Cocaine Coke, crack, white

lady, blow, etc.
Marijuana Weed, herb, grass,
refer, pot, ganja, etc.
 Example of A Stem
Change
Concern: General question Vs
specific questions that will ensure
that all questions are answered by
all respondents

Original (OAS) Change

Have you taken any Have you taken any of
drugs within the 6 the following within the
hours preceding your 6 hours preceding your
injury injury
Alcohol
 Layout In The Event of Lab
Confirmation
Blind Vs Not Blind
If Not, questions and Lab results on same
form
No means to connect necessary
IF blind, questions and lab results are
separated
Unique identifiers are needed to re-unite

NB: identifiers can be added after A&E but

before transfer to lab
 Other Useful Suggestions
Skip patterns are more difficult for
respondents to follow correctly than a simple,
uninterrupted series of questions; therefore, it
is advised that they be minimized.
Pre-test by getting a limited number of like
respondents to complete the questionnaire.
Determine average time to complete.
individually interview them about whether the
instructions were clear and whether there were
any questions or answers that they had difficulty
understanding or using.
Determine if they understood each class of drug
 Other Useful Suggestions
Contd
Pilot testing to:
see how the actual administration
procedures in the ER will go,
see how long it takes the patients to
answer the questions and
identify remaining problems in the
content and clarity of the questionnaire.
Emergency Room
Survey
Data Collection Procedure
Decisions Prior to Collection
WHAT What data will be collected
WHO Who will be responsible for data
collection
WHEN When to collect data to ensure
a normal sample
WHERE What hospitals are to be included
HOW How to conduct all aspects of
survey administration
 What data will be collected
Questionnaires
SIDUC
Bahamas
Lab confirmation data
Site reports on:
# refusals
# ineligibles
 Who will be responsible for
data collection
Conducting the interview of each section of the
questionnaire
How to select survey leaders
A&E Data Flow
Lab sample flow
routinely collected information
Ensuring that a continuous supply of
questionnaires are available
Ensuring a continuous supply of lab sampling
equipment are available (?)
Ensuring that completed forms and lab samples
are routed properly
 Selection of Survey Leader
ER Staf Research Assistant
Pros: Pros:
already in the ER
More consistency across
know the ER and are
familiar with ER routines
hospitals
Patients may feel more Cons
comfortable with MD or More expensive
Nurse doubts regarding the
least expensive ability to convince patients
Cons: to participate
Competing interests
ER Services Vs survey
completion
E.g., Social Workers in
Haiti
 When to collect data
SIDUC - Sample

Vs

Institutionalized
routinely collected
as part of diagnosis
 Timing of Data Collection
It is important to choose a period which should not be preceded
by any holiday, ensuring that the patients refer to a normal
week or month when answering the questionnaire
If more than one hospital is included, it is a must to administer
the data collection at the same time in all hospitals
In the event of inter-country comparisons (SIDUC), the time of
data collection must be as similar as possible since the use of
alcohol and other drugs vary at certain identifiable periods.
e.g. December (Christmas)
January (Recuperation)
Holidays
Lent
Where will data collection take
place
Geographic location
Islands
Hospitals
Public
Princess Margaret (Nassau)
Rand Memorial (Freeport)
Private
Doctors (Nassau)
 Activities During
Administration

Instructions to the Survey Data

Collection Staff
Instructions to the patients
Stress anonymity and confidentiality
 Who Should Complete
Survey
1. InclusionCriteria
2. Exclusion Criteria
Persons < 12 years of age
Gynae patients
Language barriers (Non-English speaking)
Unconscious patients (?)
If hospitalized and no identifiers to follow-up
 Patients who Refuse
Concern is due to the possible association
between refusal and drug use:
It is important that the number of refusals be
documented
Could compare % refusals from low and high
prevalence areas
It is important that refusals are treated in the
same way in all participating hospitals and
countries.
 Survey Administration:
Instructions to Patients
Survey Instructions can be written on the front
page of the questionnaire and should include
information on:

The purpose of the study (If not incorporated into the

system)
The selection of patients (All selected during study period)
The study is anonymous and/or confidential
Steps to ensure anonymity
Participation is important but if not willing, that is their
choice
 To Ensure Anonymity
Following SIDUC Method
Questionnaires should not contain any
identifiers
Name
hospital record #, etc.
 Survey Administration:
Report
A report should be completed (periodically) by the
survey leader
Total number of refusals
If the study only targets a specific group, the
number of those excluded
 Checklist For Data
Collection
Chose a survey leader trusted by the patients
Instructions to the survey leader
Describe how to treat patients not belonging to the target
population
Describe how to treat refusals
Careful planning of the contacts with selected institutions
Safe transportation of material (lab component)
Detailed planning of the survey administration, including
stress anonymity and confidentiality
instructions to the survey leader
instructions to the patients
Shift report
 Overview of
Methodological
Issues:
Interpretation Of Data
 Overview of Session
Representativeness the extent to which
a sample mirrors the population of interest
Reliability
the extent to which repeated
measurements used under the same conditions
produce the same result
Validity the extent to which answers are
accurate representations of the underlying reality
that they are intended to measure
 Factors that Influence
Representativeness

The sampling method

The size of the sample
Response rate: The number of
eligible non-gynae emergency room
patients that agree to participate in
the survey
 The Method of Sampling:
Target Population
The target population in the Emergency Room
survey is, by definition, persons who chose to
come to the emergency room and excluding other
individuals who, for whatever reason, chose not
to attend.

Beware that all injured persons do not come in due to a

number of reasons (choice, inaccessibility, etc.)
Less-severely injured persons who do not come in may be the
result of reasons related to substance use
Large differences in emergency room attendance (access,
availability) between countries may make it difficult/impossible
to make meaningful international comparisons
 Method of Achieving
Representativeness

Random sampling is fundamental to

obtaining a sample that is
representative of the population
OR
Sample the entire target group
 Sample Size and
Representativeness
the number of sampled patients must be
of sufficient size
considerations must be given to the
extent of the analysis of drug habits in
different subgroups
always important to sample enough patients to be
able to analyse data separately for males and
females
Responserate must be sufficiently high
to enable representative data to be
obtained
 Categories of Response
Rates
Institutional Cooperation
Public and Private Hospitals
Patient Cooperation For Interview
Proportion Participating in Lab
Analysis
 Issues Impacting
Institutional Cooperation
An increased number of proposed
surveys has made hospitals in some
countries somewhat reluctant to allow
patients to participate directly in such
surveys
highlights the necessity of approaching
institutions with emergency rooms formally
and in a way that makes them feel that
they are part of an important study
 Issues Impacting Patient
Participation
Participation should always be voluntary
Suspicions regarding True objectives has made
patients somewhat reluctant to take time to
participate in such drug surveys
highlights the necessity of approaching patients in a way
that makes them feel that they are part of an important
study
All questionnaires should be treated confidentially
The use of questionnaires without names or other kinds
of identification
Guaranties of confidential treatment of questionnaires
and data
Promises not to report data for individual patients
 Decisions Regarding Non-
Participation
If hospitals with a large percentage of overall
ER visits refuse to participate it is essential
to do a careful analysis of the reasons
If systematic errors is suspected,
interpretation might be difficult and
international comparisons may be
jeopardised.
E.g.
refusing patients come from areas where drug and/or
alcohol consumption is known to be high
 Reliability

The extent to which repeated

measurements used under the same
conditions produce the same result
Or
Whether an indicator is consistent across
time and observers
 Methods of Measuring
Survey Reliability

To conduct repeated studies using

same methodology
By using data from different
questions within a questionnaire
Laboratory Confirmation
 Factors Influencing Study Reliability

Completeness - proportion of total

information known
All respondents answer questions
All targeted respondents take survey
Sources of Error
Instrument
Person
MD, Nurse, Med. Rec Clerk
Study Subject or Respondent
May occur at
subject selection
data collection (Subjective)
Kappa Statistic
analysis and interpretation
 Sources of Error:
Instrument and Procedures
Poor selection of questions and variables
(SIDUC)
Ambiguous questions (additional questions)
Non-response
Poor selection of study subjects (friendliest)
Failure to validate measurements, recordings
lab
 Sources of Error:
Person

Interviewer
Inter-observer variation
the way medical staff explain and/or ask questions
Opinions on extent drug/alcohol use contributed to
injury

Subject
Inter-subject variation
Different Interpretation of questions (what drugs
were thought of without prompting)
willingness, survey environment
 To Achieve Reliable Data

Thorough knowledge of study population

Unbiased selection of study subjects
Standardized, calibrated and consistent
instrument(s)
Clear, unambiguous questions
Minimal personal discomfort or
discomfiture
Interviewers, recorders thoroughly and
equally well trained
Need to validate
 Validity
The extent to which answers are accurate
representations of the underlying reality
that they are intended to measure.

In the context of emergency room surveys,

the degree to which the questionnaire
measures the aspects of patients drug
consumption that it was intended to
measure.
 Strategies to Enhance
Validity
Studies must guarantee anonymity and
confidentiality
One is to use a data collection leader trusted by the
patients
Stress anonymity during the introduction
no names or other identification marks should be on the
questionnaire (SIDUC)
The patients must also have enough time to
answer the questionnaire
important that the questionnaire is not too long
They must understand the questions
They must be willing to answer the questions
honestly
Strategies to Assess Validity
Patients willingness to co-operate
Patients comprehension
Missing data rates
Logical consistency
Reported willingness to answer honestly
The cultural context in which a survey is
conducted
Strategies to Assess Validity:
Cultural Context
Questions must be culturally or locally appropriate
Use the appropriate street-names or nicknames used
for different drugs
Willingness to admit drug use may be influenced by
the attitudes towards drugs in a given society
perceived risk of substance use, disapproval of different
kinds of substance use and the availability of different
drugs differ between countries.
Low availability + Negative attitude = less willing to admit
High availability + Positive attitudes = more willing to admit
Survey Tradition
Persons in countries where surveys are less common may
feel less comfortable answering questions about sensitive
behaviours.
 Checklist For Survey
Methodology
Representativeness
Define the target population
Assess the importance of non-students in the same age
groups as the target population
Decide a proper time for the data collection (if
international comparisons are planned)
Assess the importance of non-participating
schools/classes
Assess the importance of non-participating students

Reliability
Assess reliability (whenever possible by using data in the
questionnaire)
 Checklist For Survey
Methodology Contd
Validity
Anonymous and confidential data collection
Measure and report
Number of eliminated questionnaires
Survey leader information (from the classroom
report)
Time to answer the questionnaire
Proportion of unanswered questions
Logical consistency
Possible use of a willingness question
Possible reported use of a dummy drug
Construct validity
The End
Really
The End